Tracheostomy is a surgical procedure to create an opening (stoma) in the neck to allow direct access to the trachea. A tracheostomy tube is then inserted into the stoma to provide an airway. This lesson covers the indications, procedure, and management of tracheostomies.

I. Indications for Tracheostomy

Tracheostomy may be performed for various reasons, including:

• Prolonged mechanical ventilation: If a patient requires mechanical ventilation for an extended period (typically >10-14 days), a tracheostomy may be preferred over prolonged endotracheal intubation.
• Upper airway obstruction: Tracheostomy can bypass obstructions in the upper airway caused by tumors, trauma, or congenital abnormalities.
• Impaired airway protection: Conditions that impair the patient’s ability to protect their airway (e.g., coma, neuromuscular diseases) may necessitate a tracheostomy.
• Facilitation of pulmonary hygiene: Tracheostomy allows for easier access to the lower airways for suctioning and secretion management.

II. Tracheostomy Procedure

The tracheostomy procedure can be performed surgically or percutaneously.

• Surgical tracheostomy:
  • Performed in the operating room under general anesthesia.
  • Involves a horizontal incision in the neck and dissection through the soft tissues to expose the trachea.
  • A window is created in the trachea, and a tracheostomy tube is inserted.
• Percutaneous dilatational tracheostomy (PDT):
  • Often performed at the bedside in the ICU.
  • Involves a small incision in the neck, followed by the insertion of a needle and guidewire into the trachea.
  • Dilators are used to gradually enlarge the opening in the trachea, and a tracheostomy tube is inserted over the dilators.
  • Bronchoscopic guidance is typically used to visualize the procedure and ensure proper placement.

III. Tracheostomy Tube Components

• Outer cannula: The main body of the tracheostomy tube that remains in place.
• Inner cannula: Fits inside the outer cannula and can be removed for cleaning.
• Cuff: An inflatable balloon that seals the trachea to prevent aspiration and facilitate mechanical ventilation.
• Pilot balloon: A small balloon connected to the cuff inflation line that indicates whether the cuff is inflated.
• Obturator: A solid insert used to facilitate insertion of the tracheostomy tube.
• Flange (neck plate): The part of the tube that rests against the patient’s neck and is used to secure the tube with ties or straps.

IV. Tracheostomy Tube Management

Proper tracheostomy tube management is essential to prevent complications and ensure patient comfort.

• Humidification: The upper airway normally warms and humidifies inspired air. With a tracheostomy, this function is bypassed, so supplemental humidification is crucial.
• Suctioning: Regular suctioning is necessary to remove secretions from the airway.
  • Use sterile technique.
  • Pre-oxygenate the patient before suctioning.
  • Insert the suction catheter gently and apply suction only during withdrawal.
  • Limit each suction pass to 10-15 seconds.
• Cuff management:
  • The cuff is typically inflated to create a seal for mechanical ventilation or to prevent aspiration.
  • Cuff pressure should be monitored regularly (typically every 8 hours) using a manometer.
  • Maintain cuff pressure between 20-30 cm H2O to minimize the risk of tracheal injury.
  • Cuff deflation may be considered periodically (cuff deflation trials) if the patient is able to protect their airway, to reduce tracheal wall pressure.
• Tracheostomy care:
  • Clean the stoma site and surrounding skin with saline and gauze.
  • Change tracheostomy ties or straps regularly to prevent skin breakdown.
  • Inspect the stoma site for signs of infection (e.g., redness, swelling, drainage).
• Inner cannula care:
  • Clean or replace the inner cannula regularly to prevent obstruction. Frequency depends on the type of inner cannula and the amount of secretions.
  • Some inner cannulas are disposable, while others are reusable and require cleaning.
• Communication:
  • A tracheostomy affects the patient’s ability to speak.
  • Provide alternative communication methods, such as writing, communication boards, or speaking valves.
  • Speaking valves can be used in some patients to allow them to speak by redirecting airflow over the vocal cords during exhalation.

V. Complications of Tracheostomy

Tracheostomy can lead to several complications, which can be categorized as early or late:

• Early complications:
  • Bleeding
  • Pneumothorax
  • Air embolism
  • Subcutaneous emphysema
  • Tracheostomy tube misplacement
• Late complications:
  • Infection
  • Tracheal stenosis
  • Tracheomalacia
  • Tracheoesophageal fistula
  • Granulation tissue formation
  • Tube obstruction

VI. Weaning and Decannulation

When the patient’s underlying condition improves, the tracheostomy tube may be removed in a process called decannulation. Weaning is a gradual process that assesses the patient’s ability to breathe spontaneously and protect their airway.

• Criteria for weaning/decannulation:
  • Adequate spontaneous ventilation
  • Stable respiratory drive
  • Effective cough
  • Ability to protect the airway (e.g., gag reflex, swallowing)
  • Resolution of the underlying condition that necessitated the tracheostomy
  • FiO2 requirements ≤ 0.4
• Weaning techniques:
  • Tracheostomy tube downsizing: Progressively smaller tracheostomy tubes are used to increase the patient’s work of breathing and assess tolerance.
  • Cuff deflation trials: The cuff is deflated to assess the patient’s ability to breathe around the tube and protect the airway.
  • Speaking valve trials: A speaking valve is used to assess the patient’s ability to breathe through their upper airway and tolerate increased airflow resistance.
  • Tracheostomy capping: The tracheostomy tube is capped, forcing the patient to breathe through their upper airway. This is done for progressively longer periods.
• Decannulation procedure:
  • Ensure the patient meets the criteria for decannulation.
  • Explain the procedure to the patient and provide reassurance.
  • Suction the trachea and oropharynx.
  • Deflate the cuff (if present).
  • Remove the tracheostomy tube.
  • Apply a sterile dressing to the stoma site.
  • Monitor the patient closely for airway patency, respiratory distress, and stoma site bleeding.
  • Provide supplemental oxygen as needed.
  • Encourage the patient to cough and deep breathe.
• Post-decannulation care:
  • Monitor the stoma site for healing.
  • Educate the patient on stoma care and signs of complications.
  • Assess the patient’s voice and swallowing.
  • Provide respiratory therapy as needed.

VII. Special Considerations

There are some special considerations in tracheostomy management

• Pediatric Tracheostomy:
  • Smaller, uncuffed tubes are often used in young children.
  • Frequent tube changes may be necessary as the child grows.
  • Increased risk of complications such as tracheal stenosis.
• Home Tracheostomy Care:
  • Comprehensive education for patients and caregivers on all aspects of tracheostomy care.
  • Emergency planning, including how to manage tube dislodgement and obstruction.
  • Resources for obtaining supplies and ongoing support.
• Long-term Management:
  • Regular follow-up with a multidisciplinary team, including a physician, respiratory therapist, and speech-language pathologist.
  • Monitoring for long-term complications, such as tracheal stenosis or tracheomalacia.
  • Assessment of swallowing and communication skills.